Anesthesia for endovascular treatment in anterior circulation stroke: A systematic review and meta-analysis

Background: Endovascular treatment in patients with acute anterior circulation stroke could be performed under either conscious sedation (CS) or general anesthesia (GA). Although several studies have investigated the association between the clinical outcomes and the two anesthesia methods, consensus is lacking. Methods: PubMed and EMBASE searches were used to select full-text articles comparing the effects of GA and CS on functional outcome and complications in patients with anterior circulation ischemic stroke. Enrolled patients were assigned to receive endovascular treatment with CS or GA, with a primary outcome of functional independency within 90 days. Secondary outcomes included intracranial hemorrhage, all-cause mortality at 90 days, pneumonia, and intraprocedural complications. Results: Thirteen studies (3 RCTs and 10 observational studies), which included 3,857 patients (CS = 2,129, GA = 1,728), were eligible for the analysis. The overall analysis including the RCTs and observational studies demonstrated that the functional independence within 90 days occurred more frequently among patients with CS compared with GA (OR, 1.42; 95% CI, 1.05-1.92, p = 0.02); and the risk of mortality was higher with GA compared with CS; furthermore, CS was associated with lower rate of intracranial hemorrhage. In RCTs, GA was associated with increased functional independence (OR, 0.55; 95% CI, 0.34-0.89, p = 0.01) and successful reperfusion (OR, 0.51; 95% CI, 0.30-0.89, p = 0.02). Conclusions: In the overall analysis and observational studies, CS was associated with improved functional outcomes and relatively safe for anterior ischemic stroke compared with GA. While the pooled data from RCTs suggested that GA was associated with improved outcomes. The inconsistency indicated that more large-scale RCTs are required to evaluate what factors influenced the effect of the anesthesia methods on clinical outcomes.